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California Quits: Transforming Health Systems for Tobacco Treatment Integration

Learn about the CA Quits project, promoting tobacco cessation treatment integration in health systems. Discover origins, Medi-Cal incentives, system examples, and the role of providers and plans. Collaboration with public health partners is vital.

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California Quits: Transforming Health Systems for Tobacco Treatment Integration

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  1. CA QuitsSupporting Health Systems Change for Tobacco Treatment IntegrationElisa Tong, MD Project Director, CA QuitsAssociate Professor, UC Davis January 14, 2019 Sacramento Right Care Initiative Meeting Funded by the California Tobacco Control Program: #17-10594

  2. OBJECTIVES • Brief Background: Tobacco Cessation Treatment • Origins of CA Quits • UC Quits • Medi-Cal Incentives to Quit Smoking project • CA Quits: System Examples • Providers • Plans • Public Health Partners

  3. Tobacco Prevalence: State vs. Sacramento Sacramento N=3.2 million

  4. Maternal Infant Health Survey: Tobacco Use

  5. The addiction to nicotine The habit of using tobacco Treatment Treatment Medications for cessation Behavior change program Tobacco Dependence: 2-part Problem Tobacco Dependence Physiological Behavioral Adapted from rxforchange.ucsf.edu

  6. The 5 A’s of Tobacco Treatment Tobacco Use Assessment Tobacco Counseling -Advice -Meds -Referrals Adapted from rxforchange.ucsf.edu

  7. California Smokers’ Helpline Free telephone counseling to develop a quit plan • 25th year, based at UC San Diego • Doubles chances of long-term quitting (Zhu et al. NEJM 2002) Services: • Self-help materials, local resources, text & app • Up to six follow-up sessions • Some free nicotine patch offers (First 5, Asian) • Languages: English, Spanish, Chinese, Korean, Vietnamese • M-F 7am-9pm; Sat/Sun 9am-5pm www.nobutts.org

  8. 2009: Quit Plan for California Social norm change model “Promoting services that help smokers quit: marketing a statewide tobacco quitline and encouraging health care providers and other professionals to refer tobacco users to it” Implementation plan • Health care systems change • Engage health care providers • Engage other systems • Behavioral health, social service, employers Roeseler A, Anderson CM, Hansen K, Arnold M, Zhu SH. 2010. Creating Positive Turbulence: A Tobacco Quit Plan for California. Sacramento, CA: California Department of Public Health, California Tobacco Control Program

  9. OBJECTIVES • Brief Background: Tobacco Cessation Treatment • Origins of CA Quits • UC Quits • Medi-Cal Incentives to Quit Smoking project • CA Quits: System Examples • Providers • Plans • Public Health Partners

  10. What is CA Quits? New statewide project to accelerate health system integration of tobacco treatment • Connect with the California Smokers’ Helpline • Collaborate across providers, plans, and public health partners

  11. Health Systems Changes Prioritizing Tobacco PLANS PROVIDERS Electronic Medical Records Quality metrics: Tobacco Medi-Cal expansion: 1 of 3 in CA Affordable Care Act: coverage

  12. UC Quits Medi-Cal Incentives to Quit Smoking (MIQS) • eReferrals to the Helpline • Incentives for quality metrics • Outreach with providers & plans • Incentives increased calls & quits bit.ly/ajpmdec18 (AJPM supplement)

  13. UC Quits: Two-way eReferral to Helpline 13x increased likelihood of patients connecting to quitline* • 2013: UC Davis sets up California eReferral • 2014-2015: “UC Quits” scale-up • 2018: 10,000+ eReferrals *Vidrine J et al. Ask Advise Connect: a new approach to smoking treatment delivery in health care settings. JAMA Int Med 2013

  14. UC Quits: Website & Education www.ucquits.com

  15. MIQS: Helpline Calls (March 2012 - July 2015) Total Medi-Cal Calls: 92,900 • 70% increase from prior years • Completed Counseling • 62,234 (67.0%) Incentives: 51,335 • Asked for $20 Incentive • 11,523 (12.4%) • Higher in subgroups: African Amer., Amer. Indian, 45-64 yo • Sent nicotine patch • 39,812 (73.4% when available) Tong EK et al. The Medi-Cal Incentives to Quit Smoking Project: Impact of Statewide Outreach through Health Channels. AJPM Dec 2018 https://doi.org/10.1016/j.amepre.2018.07.031

  16. MIQS: Medi-Cal vs. Non-Medi-Cal Calls REACH REFERRAL SOURCE p value <0.0001 Reach = Helpline Callers / Smoker Population in California Health Interview Survey Tong EK et al. The Medi-Cal Incentives to Quit Smoking Project: Impact of Statewide Outreach through Health Channels. AJPM Dec 2018 https://doi.org/10.1016/j.amepre.2018.07.031

  17. MIQS: Helpline Calls in Sacramento County: Medi-Cal Calls (6989) among Non-Medi-Cal Helpline Calls

  18. MIQS: Direct-to-Member Plan MailingsIncrease in Helpline Callers who “Ask for $20” after Mailings

  19. OBJECTIVES • Brief Background: Tobacco Cessation Treatment • Origins of CA Quits • UC Quits • Medi-Cal Incentives to Quit Smoking project • CA Quits: System Examples • Providers • Plans • Public Health Partners

  20. CA Quits Vision:Facilitate Partnerships for Population-based Cessation Providers Plans Public Health

  21. CA Quits: 5-Year Scope of Work • 30 safety net healthcare systems will integrate evidence- based tobacco treatment, and refer patients to the Helpline • Strategy: Learning collaboratives, capacity building, technical assistance, provider incentives, resources • 5 Medi-Cal managed care plans will participate in a tobacco work group and refer members to the Helpline • Strategy: Technical assistance, mailing resources, connecting to partners

  22. Providers: Tobacco Learning Collaborative forDHCS PRIME Quality Improvement Program Tobacco Assessment and Counseling Quality Metric = (Nonsmokers + Smokers Counseled) (Clinic patients seen in past 2 years) eCQM CMS 138v6 requires reporting out smoker population

  23. Providers:Addressing the Tobacco Quality Metric ASSESS ASK ALL: “Have you used tobacco products in the past month, including electronic devices?” ASK NONSMOKERS: “Have you been regularly exposed to tobacco smoke in the past month?” COUNSEL Provider advice • Doubles chances of quitting Medications (7 FDA-approved) • Nicotine patch +/- gum/lozenge (combo tx) • Nicotine inhaler or nasal spray • Varenicline or bupropion Referral • California Smokers’ Helpline

  24. Providers: Collaborative Sharing Workflows

  25. Providers: Onboarding Helpline eReferrals

  26. Helpline = Public Health Registry http://hie.cdph.ca.gov/specialized-registries.html

  27. Providers: California Pharmacists Kaweah Delta in Tulare County: Pharmacist telephone–based program

  28. Providers: Specialty CareUCD Comprehensive Cancer Center: NCI Cessation Initiative FIRST YEAR • Trained MAs assessment • Outreach to clinic providers and support staff on existing referral tools for quitline and group class • Follow-up 6 months about quitting NEXT STEPS • Pilot for MA referral to quitline • Pilot for MyChart population message

  29. Providers: Future Affinity Groups • Family planning clinics • Indian Health Service • Community health centers • Federally Qualified Health Centers • Veterans Affairs Behavioral Health Oral Health

  30. Plans: Medi-Cal “All-Plan Letter” on Tobacco 1) Initial and annual assessment of tobacco use for each adolescent and adult beneficiary 2) Cover FDA-approved tobacco cessation medications (for non-pregnant adults) 3) Individual, group, and telephone counseling for beneficiaries of any age who use tobacco products 4) Services for pregnant tobacco users 5) Prevention of tobacco use in children and adolescents 6) Provider training 7) Identifying tobacco users by Managed Care Plan providers 8) Tracking treatment utilization of tobacco users www.dhcs.ca.gov/formsandpubs/Documents/MMCDAPLsandPolicyLetters/APL2016/APL16-014.pdf

  31. Plan Example: Collaboration with Molina Molina 10/2018 mailing sent to smokers identified with COPD (n=4000) and DM (n=7000) Co-branded flyer available in English & Spanish Includes Helpline Promo Code to track callers Future need: Turn incentives back on!

  32. Public Health Partners:Sacramento County Tobacco Ed Program Objective by June 30, 2021: Three health or social service programs, such as alcohol and drug treatment, mental health treatment, homeless shelters/transitional housing, Federally Qualified Health Centers (FQHCs), clinics, and hospital sites in Sacramento County will adopt a voluntary policy to implement a screening and referral protocol, such as Ask, Advise, and Refer(AAR). Referrals will be made to local and state cessation resources such as to local cessation classes and the California Smokers' Helpline www.nobutts.org/county-listing

  33. Priority Population Partners (Sac County) • The Saving Our Legacy (SOL) Project: African Americans for Smoke-Free Safe Places • Health Education CouncilLUCHA Tabaco - Gold Country! Latinos Unidos Contra el Habito y Adiccion al Tabaco (Fight Tobacco - Gold Country! Latinos United against the Consumption, Habit and Addiction to Tobacco)

  34. Public Health Partnership @UCD • Host for Cessation Task Force • Sponsors for UC Davis Health’s Smoke & Tobacco-free Campus 10th anniversary • Provided training for UCD Emergency Department Research Assistants for quitline referrals • Provided quit kits for patients

  35. Next Action Steps • Connect statewide • California Smokers’ Helpline • CA Quits • Share regionally • SactoCounty Tobacco Control Coalition • Engage patients • Providers • Plans • Public health

  36. Learn more about MIQS: American Journal of Preventive Medicine Dec 2018 Supplement bit.ly/ajpmdec18 • California smokers with Medicaid • RCT of incentives and patches on cessation • Cost-benefit analysis of incentives • Statewide Outreach • Population impact for subgroups • Effect of incentives on direct-to-member demand • Direct-to-member mailing methodology • Building CA Quits and next steps Contact: Elisa Tong, ektong@ucdavis.edu Funded by the California Tobacco Control Program

  37. Connect with us: www.caquits.com • Elisa TongProject Directorektong@ucdavis.edu • Cindy Vela Plan & Partner Managercvela@ucdavis.edu • MoreenSharmaPRIME Health Systems Coordinator mmsharma@ucdavis.edu • Mary BradsberryQuality Data Analystmbradsberry@ucdavis.edu • Jackie KaslowOperations Directoraakaslow@ucdavis.edu • Rebecca HsiehCommunication & Education Coordinator rthsieh@ucdavis.edu • Shannon HaggittStatewide Health Systems Coordinatorsrhaggitt@ucdavis.edu

  38. DISCUSSION • What can you share from your own quality improvement experiences? • How many smokers? What % counseled or referred? • Population health: follow-up on quitting? • What challenges or needs do you have? • Next action steps?

  39. Federally Qualified Health Centers in Sacramento and Surrounding Counties:Adults Screened for Tobacco Use and Receiving Cessation Intervention, 2017 UDS Report Sacramento County Surrounding Counties *Includes compiled data for all sites some of which are not in Sacramento County. Source: https://bphc.hrsa.gov/uds/datacenter.aspx?q=d&year=2017&state=CA#glist

  40. eCQM Tobacco Screening & Intervention 11/2018 https://help.practicefusion.com/s/article/2018-eCQM-Preventive-Care-and-Screening-Tobacco-Use-Screening-and-Cessation-Intervention-CMS-138v6

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